TAVR for intermediate risk. Death of surgical AVR?

[sevoflurane]

April 9th, 2016

http://www.nejm.org/doi/full/10.1056/NEJMoa1514616

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[Chloroform4Life]

Another procedure for cardiologists to take away from the CV surgeons.

 

[caligas]

Still have to see about long term durability.

 

[OB1🤙]

Surgical avr will soon be dead. TAVR will take over. Low risk patients will be approved by the end of the decade.

Durability appears as good thus far as surgical valves.

There's just no reason to subject patients to surgery given the advances in TAVR.

And redo surgical avr for bioprosthetic valves should cease to exist, outside of endocarditis. It's just not ethical anymore.

 

[deleted171991]

Is this another hit for cardiac anesthesia, too? There seem to be more cardiac anesthesiologists than needed already.

 

[caligas]

Is this another hit for cardiac anesthesia, too? There seem to be more cardiac anesthesiologists than needed already.

Right now cardiac folks are the ones doing the tavrs, but maybe someday it will be like a colonoscopy.

 

[Ignatius J]

Right now cardiac folks are the ones doing the tavrs, but maybe someday it will be like a colonoscopy.

I heard a machine can do it.

 

[deleted59964]

Is this another hit for cardiac anesthesia, too? There seem to be more cardiac anesthesiologists than needed already.

As long as you can place lines in under 4.5min you should find work

 

[deleted171991]

I heard a machine can do it.

A CRNA can do it.

 

[Direct Laryngoscopy]

If complications occur, the pendulum may swing back. But we're not there yet. But yes, its a CRNA level case, since there are no differences in outcomes

 

[Planktonmd]

The future is for less invasive procedures and cardiac surgery as we know it now is going to follow the foot steps of other obsolete surgical treatments.
Very soon we will remember open heart procedures the same way we remember Billiroth one and two for the treatment of refractory gastric ulcers before the invention of H2 inhibitors and PPIs !

 

[vector2]

Right now cardiac folks are the ones doing the tavrs, but maybe someday it will be like a colonoscopy.

After having sat over a dozen TAVRs as a resident (all MACs other than a few transapicals and the one guy whose nose wouldn't stop bleeding after nasal trumpet insertion), there's no reason imo that the case couldn't be done by any competent anesthesiologist assuming cards and not anesthesia is doing the TEE/TTE. However, if the back up plan is to crash on bypass if catastrophe occurs after deployment then that might be a different story.

 

[TIVAndy]

i heard some institutions are doing TAVRs under local anesthesia, with no anesthesia presence. obviously it wouldn't be for transapical or high risk., but it seems it is becoming more like stent placement

 

[OUAnesthesia]

i heard some institutions are doing TAVRs under local anesthesia, with no anesthesia presence. obviously it wouldn't be for transapical or high risk., but it seems it is becoming more like stent placement

The last one I did was under local...50mcg of Fentanyl total for the case. TTE after valve deployment.

 

[sevoflurane]

Minimalist approach is perfectly acceptable in the right patient.
As with any MAC, patient selection is key.
Keep in mind that there is no problem doing them asleep either.
The end result in either case is an awake patient shortly after the procedure is completed.
In the case of a general TAVR, the addition of TEE is valuable pre, intra and post-op.
You do enough of them and you will crash onto bypass or have to rescue patients from imminent mortality-- Just like the cath lab may have an acute LAD dissection when trying to place a stent. These things happen, except that when bad things happen in a TAVR, they can go south very fast.

That being said a 1-2 hour AVR is an amazing contribution to medicine.

Now that intermediate risk is out there, TAVRs will become the norm.

 

[OB1🤙]

We do these with either propofol or precedex sedation, nothing else.

We don't put in our own Aline or CVC either. Slave the groin lines. This is the major advantage of MAC- you save the nontrivial time of lines and intubation. Lets you squeeze in another case into a TAVR day and make everyone happy. 4-5 cases in a day is easily doable this way.

No narcs or benzos ever (unless on chronic). No narcs for GA either.

About 80% of ours are MAC.

 

[OB1🤙]

I think a cardiac anesthesiologist should be around close by, but staffing the case with a good generalist who is comfortable around sick people is fine.

If they get a preop TEE (and less and less of ours do), that's a harder anesthetic on average than the typical TAVR nowadays.

 

[Chloroform4Life]

There are plenty of non-fellowship trained anesthesiologists doing heart cases.

......a crna can do hearts.

 

[OB1🤙]

Note that I didn't say a fellowship-trained echo-boarded anesthesiologist should be close by.

I said a cardiac anesthesiologist.

Squares and rectangles.

You need to be comfortable resuscitating sick elderly people with structural heart disease. That's the basic requirement.

 

[deleted162650]

I said a cardiac anesthesiologist.

Squares and rectangles.

Yup, you guys are all pretty nerdy.

 

[OB1🤙]

Yup, you guys are all pretty nerdy.

 

[Magnus67]

Hold your horses guys, there's a lot of fishy literature about stroke rates. One scary article looked at subclinical strokes by doing pre-and post Tavr MRIs. 70% "silent" stroke rate on MRI post Tavr.... No thanks, you guys may be smarter than I am ,but I need all my brain cells. If I am not high risk or non-operable ill go for a sternotomy. At least until there's more data on long term neurologic complications.


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[Chloroform4Life]

Hold your horses guys, there's a lot of fishy literature about stroke rates. One scary article looked at subclinical strokes by doing pre-and post Tavr MRIs. 70% "silent" stroke rate on MRI post Tavr.... No thanks, you guys may be smarter than I am ,but I need all my brain cells. If I am not high risk or non-operable ill go for a sternotomy. At least until there's more data on long term neurologic complications.


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Heres a study for comparison with traditional AVR:

http://www.ncbi.nlm.nih.gov/pubmed/24690611

With traditional repair:
17% had clinical strokes

Of the patients who didn't have clinical stroke, 54% had silent stroke on MRI.


Does it matter if you had a stroke and its clinically silent???

 

[GA8314]

Well, I don't think cardiac anesthesiologists are going anywhere anytime soon. Also, it's not like even if ALL cardiac surgery goes away these guys won't be able to do generalist stuff. And we all know that's not gonna happen. I still think it's a great fellowship, but of course one needs to factor in supply/demand. It seems like demand is still pretty strong.

 

[BLADEMDA]

Hold your horses guys, there's a lot of fishy literature about stroke rates. One scary article looked at subclinical strokes by doing pre-and post Tavr MRIs. 70% "silent" stroke rate on MRI post Tavr.... No thanks, you guys may be smarter than I am ,but I need all my brain cells. If I am not high risk or non-operable ill go for a sternotomy. At least until there's more data on long term neurologic complications.


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"silent stroke" occurs in 54% of patients who opt for the traditional, sternotomy based AVR. If I need an AVR I'm going the TAVR route.

Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay.

 

[drmwvr]

Well, I don't think cardiac anesthesiologists are going anywhere anytime soon. Also, it's not like even if ALL cardiac surgery goes away these guys won't be able to do generalist stuff. And we all know that's not gonna happen. I still think it's a great fellowship, but of course one needs to factor in supply/demand. It seems like demand is still pretty strong.

Nope, they're not. But as long as we're speculating, just where there'll be true "cardiac anesthesiologists" is another question. Gone will be the days of "lifestyle" cardiac situations in, for lack of a better term, attractive parts of the country.

Centralized cardiac surgery is a "thing" now, apparently.

http://medcitynews.com/2010/03/lowes-alliance-with-cleveland-clinic-likely-first-of-many/

 

[invitro]

What is your guys' cocktail for doing a Mac on these patients? If the patient has severe as (Ava <1cm squares, mean gradient >40mmhg) are you all ever cautious with a propofol gtt?

I assume running a propofol drip at 150-200mcg/kg/min with a 1mg ketamine per 10mg propofol (60mg in a 60cc syringe of 600mg propofol) could do the trick.

What do you all do? Don't want to drop svr or myocardial contractility too much.

 

[mostwanted]

We do these with either propofol or precedex sedation, nothing else.

We don't put in our own Aline or CVC either. Slave the groin lines. This is the major advantage of MAC- you save the nontrivial time of lines and intubation. Lets you squeeze in another case into a TAVR day and make everyone happy. 4-5 cases in a day is easily doable this way.

No narcs or benzos ever (unless on chronic). No narcs for GA either.

About 80% of ours are MAC.

How frequently are you guys doing surgical cut down?

 

[urge]

We don't put in our own Aline or CVC either. Slave the groin lines. This is the major advantage of MAC- you save the nontrivial time of lines and intubation.

Didn't we agree that it takes us less than 4 min to put an a line, central line, and intubate?

 

[urge]

After having sat over a dozen TAVRs as a resident (all MACs other than a few transapicals and the one guy whose nose wouldn't stop bleeding after nasal trumpet insertion), there's no reason imo that the case couldn't be done by any competent anesthesiologist assuming cards and not anesthesia is doing the TEE/TTE. However, if the back up plan is to crash on bypass if catastrophe occurs after deployment then that might be a different story.

Any idiot who can induce anesthesia on a patient with critical AS without causing a cardiac arrest can do them.

There are less idiots capable of this than you think.

 

[vector2]

What is your guys' cocktail for doing a Mac on these patients? If the patient has severe as (Ava <1cm squares, mean gradient >40mmhg) are you all ever cautious with a propofol gtt?

I assume running a propofol drip at 150-200mcg/kg/min with a 1mg ketamine per 10mg propofol (60mg in a 60cc syringe of 600mg propofol) could do the trick.

What do you all do? Don't want to drop svr or myocardial contractility too much.

We hang precedex, epi, norepi. Load the precedex while putting in a-line and introducer and then run it at 0.5-1. Small boluses of fentanyl or ketamine prn. Most of these patients are 75-90yo with multiple comorbities so their baseline awake state is probably 0.5 mac. Doesn't take much. If you're deadset on using propofol I would not be running it above 40-50.

 

[itwasalladream]

I'm not sold yet. Can do them reasonably quick under GA, under 2 hours door to door including art line, quad lumen, and extubation in room. Probably faster as our cardiologists get faster (fairly new program), art line pre-op, prep faster, etc. We cut down on everybody so I really don't see precedex doing the trick to keep a still patient every time. GA keeps them completely still 99% of the time. I don't doubt that many have seen improved times with sedation, but I don't foresee a major improvement in my practice, especially since I'm not ready to give up my dedicated art line and CVC just yet. You could even argue that the patient is ready for prep/procedure faster with GA than sedation. Faster induction, easy titration when you have an established airway, paralytic on board, etc. Even if sedation is a few minutes faster it would have to be much faster to fit another TAVR in the day. More likely, dealing with sedation in order to go home just a couple minutes early doesn't sound all that appealing to me.

Rates of delirium are not different. LOS in TAVR has been claimed to be shorter, but in all those studies the programs started out doing GA, then progressed to sedation so of course the LOS would be shorter. Not sure how GA increases LOS when the patient is extubated in room after a quick, uneventful procedure. Until the valves improve further I think there will be a limit on how low you can get the hospital stay, as we have had some delayed heart block 36-48hrs out requiring emergent pacing.

I don't disagree at all that it's doable, and probably doable well. But in terms of clear tangible benefits, I don't see it. I do see clear downsides of sedation:
1) Constantly titration with sedation while trying to maintain airway on a completely still 95 yr old in hour 2 of the procedure (pain in the ass when I'd rather be concentrating on hemodynamics)
2) No airway when SHTF
3) Conversions to GA (a reported 2-5% rate at experienced centers). Won't happen if you're already at GA .
4) Outcomes are worse with moderate residual leak (I think one study even showed worse outcomes with MILD vs trace), and I don't think TTE gives that an accurate a picture in many patients. Immediately post implant trying to delineate mild vs moderate, or trace vs mild? I don't have a ton of confidence in TTE and TEE is so readily available.
5) Anyway, most of my patients would rather be completely asleep, particularly when you tell them all the needles/lines/cutdowns they're going to get and can't claim sedation is safer for them.

Fire away...

 

[OB1🤙]

What is your guys' cocktail for doing a Mac on these patients? If the patient has severe as (Ava <1cm squares, mean gradient >40mmhg) are you all ever cautious with a propofol gtt?

I assume running a propofol drip at 150-200mcg/kg/min with a 1mg ketamine per 10mg propofol (60mg in a 60cc syringe of 600mg propofol) could do the trick.

What do you all do? Don't want to drop svr or myocardial contractility too much.

That sounds like TIVA. These are older folks, they don't need much. Prop drip around 50 is usually enough. I love ketamine and use it for every open heart I do, but TAVR doesn't hurt after and the elderly can get wigged out with even a little ketamine, since the procedure is short.

How frequently are you guys doing surgical cut down?

Exactly never. With the third generation equipment, if your team is cutting down, you're doing it wrong.

Didn't we agree that it takes us less than 4 min to put an a line, central line, and intubate?

3.5 minutes, in fact.

 

[OB1🤙]

I'm not sold yet. Can do them reasonably quick under GA, under 2 hours door to door including art line, quad lumen, and extubation in room. Probably faster as our cardiologists get faster (fairly new program), art line pre-op, prep faster, etc. We cut down on everybody so I really don't see precedex doing the trick to keep a still patient every time. GA keeps them completely still 99% of the time. I don't doubt that many have seen improved times with sedation, but I don't foresee a major improvement in my practice, especially since I'm not ready to give up my dedicated art line and CVC just yet. You could even argue that the patient is ready for prep/procedure faster with GA than sedation. Faster induction, easy titration when you have an established airway, paralytic on board, etc. Even if sedation is a few minutes faster it would have to be much faster to fit another TAVR in the day. More likely, dealing with sedation in order to go home just a couple minutes early doesn't sound all that appealing to me.

Rates of delirium are not different. LOS in TAVR has been claimed to be shorter, but in all those studies the programs started out doing GA, then progressed to sedation so of course the LOS would be shorter. Not sure how GA increases LOS when the patient is extubated in room after a quick, uneventful procedure. Until the valves improve further I think there will be a limit on how low you can get the hospital stay, as we have had some delayed heart block 36-48hrs out requiring emergent pacing.

I don't disagree at all that it's doable, and probably doable well. But in terms of clear tangible benefits, I don't see it. I do see clear downsides of sedation:
1) Constantly titration with sedation while trying to maintain airway on a completely still 95 yr old in hour 2 of the procedure (pain in the ass when I'd rather be concentrating on hemodynamics)
2) No airway when SHTF
3) Conversions to GA (a reported 2-5% rate at experienced centers). Won't happen if you're already at GA .
4) Outcomes are worse with moderate residual leak (I think one study even showed worse outcomes with MILD vs trace), and I don't think TTE gives that an accurate a picture in many patients. Immediately post implant trying to delineate mild vs moderate, or trace vs mild? I don't have a ton of confidence in TTE and TEE is so readily available.
5) Anyway, most of my patients would rather be completely asleep, particularly when you tell them all the needles/lines/cutdowns they're going to get and can't claim sedation is safer for them.

Fire away...

With MAC, as soon as they're on the table, they start prepping. Load your sedative and it's on board when they're ready to stick.

I'm as slick as the next guy, but if you make me put in an a-line, induce, secure tube, prep, place cvc, all that does take time. Not huge time, but time. Say 15 minutes.

The leak argument holds much less true now. 3rd generation valves leak much, much less. Aortography is honestly usually enough to assess leak, the TTE is a good adjunct, and TEE just isn't necessary for most.

Your point of view is valid. I used to share it. I was very resistant to switching to MAC; I thought it was a stupid idea that sacrificed safety.

After we switched, my opinion turned 180. I just think it's a more elegant way to conduct the procedure, and the evidence bears out that it's at least as safe, and definitely associated with reduced procedure time and cost.

 

[deleted171991]

Any idiot who can induce anesthesia on a patient with critical AS without causing a cardiac arrest can do them.

There are less idiots capable of this than you think.

A touch of versed, awake a-line, a touch more of versed, a touch of propofol, some gas and other stuff as needed, a lot of patience, a pinch of salt... Et voila! Truth be told, as a former solo outpatient guy, I Know MAC, I Know those drugs, and I Know titration.

I am always dumbfounded when I see CCM attendings push 1.5-2 mg/kg of propofol in sick ICU patients, then act all surprised when the patient almost codes. Anesthesia attendings included, even after I tell them not to. Seriously, what's so hard in titrating, when one has an a-line in place?

 

[BLADEMDA]

A touch of versed, awake a-line, a touch more of versed, a touch of propofol, some gas and other stuff as needed, a lot of patience, a pinch of salt... Et voila! Truth be told, as a former solo outpatient guy, I Know MAC, I Know those drugs, and I Know titration.

I am always dumbfounded when I see CCM attendings push 1.5-2 mg/kg of propofol in sick ICU patients, then act all surprised when the patient almost codes. Anesthesia attendings included, even after I tell them not to. Seriously, what's so hard in titrating, when one has an a-line in place?

The majority of patients need far less than 1.5 mg/kg IV of propofol if you are willing to go slowly with the induction. Typically, our elderly patients or ICU ones need 1.0 mg/kg IV at most but you must be willing to wait for the propofol to circulate and take effect.

 

[BLADEMDA]

European Journal of Anaesthesiology:
June 2011 - Volume 28 - Issue - p 222
Abstracts and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Perioperative Care of the Elderly
How much propofol should be given to the elderly for induction of anaesthesia? A prospective study based on change of bispectral index (BIS) values: 18AP1‐5
Hascilowicz, T.; Hamaguchi, T.; Nakata, S.; Yamamoto, Y.; Kiyama, S.; Uezono, S.

Free Access

Author Information

Jikei University School of Medicine, Department of Anaesthesiology, Tokyo, Japan

Background and Goal of Study: Quantitative relationship between BIS values and propofol doses has not been extensively studied. The generally recommended dose for induction has a wide range (1 to 2.5 mg/kg), which may cause too deep sedation in the elderly. The goal of the study was to quantitatively assess the effect of propofol on BIS during induction and compare its features between younger and older patients.

Materials and Methods: After obtaining informed consent, 72 patients (38 men and 34 women, ASA PS 1 or 2) undergoing elective non‐cardiac surgery were assigned to either below/equal to 60 or above 60 years of age group (younger and older group). They were randomly allocated to one of three subgroups (12 subjects in each subgroup) depending on the dose of propofol: 1.5, 2.0 or 2.5 mg/kg (younger group) or 1.0, 1.5 or 2.0 mg/kg group (older group). Bolus doses of propofol were administered following 40 mg of intravenous lignocaine. Fentanyl (2 mg/kg) and rocuronium (0.9 mg/kg) were given at 1.5 and 2 minutes after injection of propofol, respectively.

The difference between the baseline and minimum BIS value (ΔBIS) during the first 5 minutes after propofol injection was compared between the two age groups.

Results and Discussion: The mean ages of younger and older patients were 41 and 69 years, respectively. The ΔBIS were normally distributed within the subgroups (Shapiro‐Wilk test), and their means varied between the subgroups (one‐way ANOVA; P =0.029 and P < 0.001 in younger and older group, respectively).

A linear regression analysis demonstrated a good fit correlation between ΔBIS values and doses of propofol in both age groups (adjusted R2 values of 0.97 and 0.93 for younger and older group, respectively).

Conclusion(s): A dose‐dependent relationship between propofol dose and ΔBIS exists. Based on the change of BIS values during induction, 1.0 mg/kg of propofol is sufficient to provide adequate depth of anaesthesia in elderly patients.

 

[BLADEMDA]

Sedation dosages (I don't use 1 mg/kg of ketamine but more like 0.5 mg/kg up to about 80-100 mg IV total)

 

[vector2]

A touch of versed, awake a-line, a touch more of versed, a touch of propofol, some gas and other stuff as needed, a lot of patience, a pinch of salt... Et voila! Truth be told, as a former solo outpatient guy, I Know MAC, I Know those drugs, and I Know titration.

I am always dumbfounded when I see CCM attendings push 1.5-2 mg/kg of propofol in sick ICU patients, then act all surprised when the patient almost codes. Anesthesia attendings included, even after I tell them not to. Seriously, what's so hard in titrating, when one has an a-line in place?

Sick icu patients (already on pressors and about to decompensate on bipap) essentially need 16mcg norepi, 4-6mg of etomidate (or possibly just straight versed), then push the sux. Every now and then we go to the ICU and act as backup to the ICU fellow who wants to intubate and I have to slap them when they think the almost-coding patient needs 30mg of etomidate.

 

[itwasalladream]

With MAC, as soon as they're on the table, they start prepping. Load your sedative and it's on board when they're ready to stick.

I'm as slick as the next guy, but if you make me put in an a-line, induce, secure tube, prep, place cvc, all that does take time. Not huge time, but time. Say 15 minutes.

The leak argument holds much less true now. 3rd generation valves leak much, much less. Aortography is honestly usually enough to assess leak, the TTE is a good adjunct, and TEE just isn't necessary for most.

Your point of view is valid. I used to share it. I was very resistant to switching to MAC; I thought it was a stupid idea that sacrificed safety.

After we switched, my opinion turned 180. I just think it's a more elegant way to conduct the procedure, and the evidence bears out that it's at least as safe, and definitely associated with reduced procedure time and cost.

All good points, and reasons I'm on the fence but still haven't jumped. If someone pushed me, I probably wouldn't fight it that hard either.

I will say that recently, we have post-dilated an S3 due to leak. This is with experienced reps sizing in addition to our own docs. Also recently, a TEE has shown mild to mod leak (on S3) while aortography has shown trace. Which is better? In a related scenario, I trust a TEE's assessment of MR more than a cath grading. If you're mainly doing aortography, and TTE as an adjunct, is it possible you're missing some mild-moderate leaks that get downgraded to trace-mild? Maybe it doesn't matter...but aside from this TEE is helpful in an emergency.

On the time thing - your minimalist approach is slick, but if you're taking a more conservative approach with lines (as I suspect most people doing MAC are), you still have to account for the time it takes to put in those lines under sedation. A sedated central line would actually be a couple extra minutes for me. So most of the 15 minutes of saved time is from skipping lines in order to slave. Which (just personal opinion) is slightly less safe in the rare emergency.

As for the cost thing, not sure I follow. Are you just extrapolating from reduced OR times?

So in all, I think:
It's a bigger PITA, particularly since our guys are still cutting down
Safety is close but not quite equal
Reduced procedure time is questionable unless you skip lines
Elegance/sexiness shouldn't matter

I appreciate your perspective though because I'm torn in some respects. And maybe one day soon I'll look back at this post and laugh.

 

[Laryngophed]

Heres a study for comparison with traditional AVR:

http://www.ncbi.nlm.nih.gov/pubmed/24690611

With traditional repair:
17% had clinical strokes

Of the patients who didn't have clinical stroke, 54% had silent stroke on MRI.


Does it matter if you had a stroke and its clinically silent???

Yes, because stroke recrudescence is a thing.

 

[Twiggidy]

The majority of patients need far less than 1.5 mg/kg IV of propofol if you are willing to go slowly with the induction. Typically, our elderly patients or ICU ones need 1.0 mg/kg IV at most but you must be willing to wait for the propofol to circulate and take effect.

My practice totally changed once I learned this. I went through training thinking everyone got 200mcg of propofol (400mcg if obese) and if your heart stunk pull out the etomidate. That was until I have a very smart ICU attending and very hot (and hot cardiac attending who I still crush on to this day) tell me that can go their entire career and never touch etomidate and only use propofol. Today, I induce just about all of my hearts with propofol, short of the "Oh damn I'm about to die because my SBP is 60 and I'm a take back" hearts.

 

[G-Man82]

My favorite icu inductions:
Midazolam until eyes close, then slug of Roc or sux

Or, for the truly physiologically difficult airway, I'll do a Transtracheal block with 3 ml of 2% lidocaine, a one-second spray of hurricane spray, a touch of ketamine or midazolam, and an essentially "awake" glidescope in the sitting bolt-upright position from the front. Minimal swings in hemodynamics. Plus, with that lidocaine, they tolerate the presence of the tube for some time --> less sedation needed in the immediate post-intubation period.

This also works well in the OR for emergent cases where hemodynamics becomes a more than usual major concern. I've also done the bolt upright intubation from the front for morbidly obese patients. But I'm young in my career ...

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[urge]

My practice totally changed once I learned this. I went through training thinking everyone got 200mcg of propofol (400mcg if obese) and if your heart stunk pull out the etomidate. That was until I have a very smart ICU attending and very hot (and hot cardiac attending who I still crush on to this day) tell me that can go their entire career and never touch etomidate and only use propofol. Today, I induce just about all of my hearts with propofol, short of the "Oh damn I'm about to die because my SBP is 60 and I'm a take back" hearts.

I had an attending rip me a new hole in front of all the OR staff because I was inducing with too little propofol. Said attending claimed I was putting the patients in stage 2 anesthesia and was risking a laryngospasm.

What do you say to that? "Hey dumb f, there is no stage 2 with propofol!"

I was a resident so I went for the "thanks for the teaching" line.

The joys of being supervised by a fool.

 

[Planktonmd]

I had an attending rip me a new hole in front of all the OR staff because I was inducing with too little propofol. Said attending claimed I was putting the patients in stage 2 anesthesia and was risking a laryngospasm.

What do you say to that? "Hey dumb f, there is no stage 2 with propofol!"

I was a resident so I went for the "thanks for the teaching" line.

The joys of being supervised by a fool.

It might not be "stage 2" but you certainly can cause laryngospasm and a very bumpy LMA insertion if your Propofol dose is not sufficient!
This naturally would not be an issue if you are using a muscle relaxant with Propofol, but the hemodynamic effects of airway instrumentation might be harmful for the patient if the induction dose was too small as you know.

 

[deleted162650]

I had an attending rip me a new hole in front of all the OR staff because I was inducing with too little propofol. Said attending claimed I was putting the patients in stage 2 anesthesia and was risking a laryngospasm.

You're too nice. I would have something to the effect of "that's what the muscle relaxant is for you crap-weasel." Okay well maybe not the crap weasel part but I sure woulda said something about he paralytic in the most passive-aggressive way possible.

I remember one time in residency a few of my co-residents and I asked our (very approachable) program director why some of the particularly clinically weak staff were allowed to continue "teaching" residents (let alone remain employed). With a smile and and a wink he said "It's important for you guys to have some negative role models too."

 

[pgg]

What do you say to that? "Hey dumb f, there is no stage 2 with propofol!"

Not defending the doofus, but I feel compelled to make two devil's advocate points.

Propofol inductions certainly do pass through stage two, but it's so much faster than an inhalation induction (or emergence) that it's a negligible period of time.

People who are under too-light anesthesia (without relaxant) can obviously move and intermittently approximate their vocal cords during DL. Is that "laryngospasm"? Maybe not, but it can interfere with passing a tube. Maybe that was his worry?

 

[seinfeld]

I have done TAVRs many different ways. What i have found matters most is using TIVA whether "MAC" or GA with ETT. I think we all underestimate the effects inhaled agents and residual paralysis have on the elderly. Also I think we too often use gas to control hemodynamics when the background EEG, which is often unknown, if markedly suppressed. Regarding paralysis in the elderly its hard to get the exact dose of neostigmine right, too much or too little seem to both be detrimental.

I came to this idea of TIVA after floor nursing, our femorals dont go to the ICU after PACU, starting commenting how much more awake patient were coming to them. Interestingly the only thing we did differently was to use propofol at 50-80mcg/kg/min +100-200mcg of fentanyl , sux for ETT or no sux if not intubated. (that right we use the same dosing for GA as MAC and cardiologists love talking about how we do TAVR with sedation, we still bill for a GA though ) I have no real data to back it up but to me its an interesting thought.

Most of these cases dont need us, but because i am there i feel like I need to provide better anesthesia than 1mg of versed and 50mcg of fentanyl.

What are people conversion rates to CPB? <1% greater than 2% ?

Those that are concerned about myocardial depressive effects of propofol are a bit too academic IMHO. I induce ALL my hearts with some dose of propofol and unlike some of my partners who have had death on induction over the years with large versed and fentanyl doses gotta say that I dont see it. I watch my BP closely , titirate my drugs to effects and in most instances i use less than 500mcg of phenylephrine pre-CPB. Any one here ever induce a sick heart hip fracture patient with 10mg of versed and 500mcg of fentanyl ? or an AICD placement the same way they induce a MVR/TVR CABG?

 

[urge]

It might not be "stage 2" but you certainly can cause laryngospasm and a very bumpy LMA insertion if your Propofol dose is not sufficient!
This naturally would not be an issue if you are using a muscle relaxant with Propofol, but the hemodynamic effects of airway instrumentation might be harmful for the patient if the induction dose was too small as you know.

No LMA.

Back then I was being cautious and was inducing slowly. Also making sure I could ventilate before giving muscle paralysis.

Gave versed and fentanyl. O2 mask. Gave 50mg propofol bump and wait about 20 secs. If apneic check if I could ventilate before committing to the muscle relaxant. If not apneic, give another propofol bump and wait until apnea, or another propofol bump. Then add another propofol bump, or gas, for the laryngoscopy.

Most people do not need much propofol before going apneic if you give enough fentanyl.

This attending flipped when she saw me masking the patient with only 50mg of propofol on board.

I have yet to see a patient go through stage 2 with propofol. It might be an EEG phenomenon but I have yet to see anyone get excited.

PS: funny thing is that I do the same induction with a much senior attending (don't remember now if before or after the previously described incident) and the BP tanks to like 50/30 with only 50mg of propofol. The attending is thanking me for not slugging all the propofol in, and confesses that he had given enalaprilat iv in holding because the pt came hypertensive.

 

[deleted162650]

(that right we use the same dosing for GA as MAC and cardiologists love talking about how we do TAVR with sedation, we still bill for a GA though )

Ugh. Can people get it through their thick skulls that GA and MAC bill at exactly the same rate.

And now back to TAVR's